Scottsdale psychiatrist Michael Yasinski M.D discusses the Colorado shooting from a psychiatric perspective.

As more information emerges about the Colorado shooting and the suspect, James Holmes, more speculation and erroneous information also arises. As an information-hungry nation, we are fortunate to have access to instant information which can be great in many situations; however, it can also fuel the flames of uninformed speculation in cases such as this. With dedicated cable news stations and the opportunity for anyone to voice an opinion over the Internet, it is difficult to separate the facts from the fiction and it’s impossible to know which “expert” to trust.

As a psychiatrist, I cringe at some of the speculation that has been presented and how non-mental health professionals are portraying psychiatric illness. Even as a psychiatrist who has evaluated and treated many mentally ill individuals, I cannot begin to definitively diagnosis this man. I can, however, clarify some of the erroneous comments and misinformation which can provide some insight into how a psychiatrist may conceptualize this case.

“James Holmes is clearly psychotic.” Many people emphatically stating this without an accurate idea of what the term psychosis means. The term “psychotic” is used by the public to describe anyone who displays relatively bizarre or abnormal behavior but that conceptualization is not accurate. There is a clear meaning to the term which is important to understand and has not been adequately clarified in the media despite the term being used repeatedly.

To better understand the concept of psychosis, consider this: Have you ever had an extremely vivid and detailed dream that made perfect sense until you open your eyes. Upon waking up you realize that the dream made absolutely no sense and was filled with many impossible scenarios that seemed realistic in the dream? This is a glimpse into the mind of someone experiencing psychosis. A world filled with strange events, perceptions and behaviors that are clearly unrealistic to the normal population, but feels completely real to the psychotic person.

“Loss of reality testing” is often a term used to describe the psychotic mind. The loss of reality testing means the loss of the shared world and with it the loss of meaningful communication with others. If a person's perceptions are so different that they become "unreal" to us, we stop being able to understand what is being said. If a person assigns meanings to a word that bear no similarity to the meanings we assign, then the same words may be used but no meaning is exchanged. The disturbed person becomes isolated because he no longer experiences or understands the world in the way that we do.

The two most common manifestations of psychosis and impaired reality testing are delusions and hallucinations. Delusions defined as “a belief held with strong conviction despite superior evidence to the contrary.” Hallucinations as defined as a perception in the absence of an actual external stimulus. These perceptions are experienced as completely real to the person and considered not real by the rest of society. People experiencing psychotic delusions or hallucinations do not have any insight into the fact that the perceptions they are experiencing are irrational or not shared by the rest of society. They become fully submerged into their disconnected thoughts.

While some someone experiencing psychosis partly disconnected from certain aspects of reality, it does not mean they are unable to carry out a premeditated plan over the course of weeks or months. Impairment parts of the brain involved in perceptions of our surroundings does not necessarily indicate impairment in the part of the brain involved in planning and execution of those plans. Whether or not James Holmes was psychotic is not clear at this point but it certainly cannot be ruled out by the fact he carried out an extensive premeditated plan.

Another example of erroneous speculation involves the understanding of the term “sociopath.” Many people have labeled the Colorado shooter as a sociopath based on a limited understanding of what that actually means. Although many serial killers and mass murderers are sociopaths, it definitely is not always the case. The diagnostic term is actually referred to as “anti-social personality disorder” and the diagnostic manual in psychiatry (DSM IV) defines it as the following:

There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another;

There is clearly not enough information available to definitively state whether or not the shooter was a true sociopath. This does not mean he actually ends up having anti-social personality disorder but there needs to be much more history and evidence to accurately make that claim.

A third theme that has emerged after the suspect’s first court appearance is whether or not he is faking his bizarre behavior both before and after the shooting. Body-language experts have even jumped in and commented on their belief he is faking the symptoms. As a psychiatrist, I have witnessed the spectrum of bizarre behavior and body language which alone cannot be used with any certainty to make an accurate diagnosis. Although faking, or more formally known as “malingering,” is common and possible, speculation about this only adds to the confusion and misperception of psychiatric illness. There are structured evaluations that will be performed as part of an extensive psychiatric evaluation that will help to determine the possibility of malingering in a much more objective manner. Until that is completed, I hesitate to over-analyze subtle movements or behaviors seen in snap-shot views of the suspect.

What has largely not been discussed in the public is one of the most important considerations to a psychiatrist in a case such as this. Ruling out an underlying medical illness that can cause extremely bizarre behavior is crucial. Brain tumors, metabolic diseases, and infections are some examples of medical problems that can cause extreme changes in personality, behavior and perception of reality. Lab tests, brain imaging and a closer physical exam will likely be conducted to rule this possibility out before definitively diagnosing a psychiatric disorder.

Regardless of the ultimate explanation of the suspect’s motives, one question remains: What could have been done to prevent this? Politicians quickly jump on gun control or legislation regarding mental health law; however, neither of these addresses the root cause of why these situations continue to happen in our society.

The real problem is the stigma attached to psychiatry and negative perceptions of mental illness. If society was more open in discussing mental illness and accepting it as a legitimate medical illness, people who experience early symptoms of a mental illness would be much more likely to seek help before they spiral out of control. The public would also be more likely to openly discuss concerns about someone rather than feeling scared to openly discuss the subject.

The openness in which we talk about cancer, diabetes and heart disease needs to be carried over to mental illness and only then will there be a significant decrease in these horrible tragedies. The first step in doing so is to properly educate the public rather than speculate about inaccurate representations of psychiatric disorders, which unfortunately has been all too common in this case. Whether or not this specific case could have been prevented with a higher awareness of psychiatric illness is unclear but moving forward, eliminating the stigma is the best defense against other similar tragedies.

Michael Yasinski MD, www.yasinskipsychiatry.com